Portal venous gas one year after laparoscopic Roux-en-Y gastric bypass. a case report of a unique pathology.

Introduction: Hepatic portal venous gas is a radiographic finding typically associated with bowel ischemia, and is considered to be a poor prognostic sign prompting urgent operative exploration. Portal venous gas frequently occurs after instrumentation of the biliary tree, and may also be seen after insufflation of the abdomen for laparoscopy. In addition, portal venous gas has been reported in a case of anastomotic leak after laparoscopic Roux-en-Y gastric bypass (LRYGB). Cases of portal venous gas associated with non-surgical conditions have been reported, and include cholangitis and severe enteritis. We examine a case of massive portal venous gas seen on computed tomography (CT) in a patient presenting with severe abdominal pain one year after uncomplicated LRYGB.

Case Report: A 36 year old male one year after LRYGB presented to the Emergency Department with a one day history of severe abdominal pain associated with nausea and vomiting. His past medical history was significant for a decrease in body mass index (BMI) from 49 preoperatively to a BMI of 30 over the year since LRYGB. Vital signs were normal, and laboratory investigations were significant only for a mildly elevated white blood cell count. On exam, the patient was in no distress; he had mild epigastric tenderness without peritoneal signs. CT scan was obtained, revealing portal venous gas and a thickened transverse colon, suggestive of bowel ischemia or colitis. The patient was taken to the operating room for urgent exploration, which was negative for peritonitis, bowel obstruction, or bowel ischemia. The transverse colon was found to be significantly thickened, suggestive of colitis. The gastric remnant was not dilated, and the Roux limb, biliary-pancreatic limb and common channel were normal. The patient had an uneventful recovery from this essentially negative laparotomy, with resolution of the portal venous gas noted on follow-up CT obtained on the third postoperative day. Stool cultures were negative for Clostridium difficile colitis, and the patient was discharged home on the fourth postoperative day.

Conclusions: The presented case suggests yet another possible etiology for portal venous gas, and should prompt further investigation into characteristics unique to patients after LRYGB that may be associated with this rare radiologic finding (CT images to be presented).

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